AVIATION OCIP Forms
This section contains the following forms:
AVIATION OCIP Form - 1GL Enrollment Application AVIATION OCIP Form - 2GL Notice of Work Completion AVIATION OCIP Form - 3GL Pre-Enrollment
AVIATION OCIP Form - 4GL General Liability Loss Report Exhibit 1 Enrolled Sample Certificate of Insurance
Exhibit 2 Excluded Sample Certificate of Insurance
Note
For assistance in completing these forms, please contact:
Nick Morgan, Program Administrator Wells Fargo Insurance Services
Phone 202-772-4244 Cell 202-815-4303
Section
8
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 1GL - Enrollment Application Metropolitan Washington Airports Authority
Page 1 of 3
*** NOTICE *** Enrollment is not automatic and requires the satisfactory completion of the AVIATION OCIP Form - 1GL.
Examine your current General Liability Policies or contact your Insurance Agent to assist you with completing this form.
In addition, submit a Certificate of Insurance providing evidence of your on-site and off-site coverages. Please refer to the Insurance Manual for coverage requirements. See page 3 of this form for instructions
A. CONTRACTOR INFORMATION: 1. Federal ID # or Soc. Sec. #
2. Business Information (headquarters) 3. Contact Information (address questions to...)
Company Name & dba
1. Your Organization’s Structure Corporation
Joint Venture
Position Name & Title Phone Fax Email Address
1. Project Manager
D. PROVIDE YOUR CURRENT WORKERS COMPENSATION INFORMATION: (for each state you will perform work in)
1. Applicable State 2. Risk ID Number 3. Rating Bureau 4. Anniversary Rating Date
5. Your WC Insurance Carrier
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 1GL - Enrollment Application
Metropolitan Washington Airports Authority
Page 2 of 3
E. SUBCONTRACT INFORMATION: Provide information on all Subcontractors that will be working for you on this project.
Please use additional paper, if necessary.
1.
F. ENROLLMENT QUESTIONS: Answer each question. Use additional paper if necessary.
1. Will you have any off-site location(s) 100% dedicated to this project?
Yes No If yes, please provide address:
2. Please check if: Any aircraft used on this project Any watercraft used on this project
3. Please indicate if labor from the following sources will be used: Employee Leasing Firm Temporary Labor Agency
4. What is your Virginia Contractor’s License Number?
5. What is your License Class A, B or C?
G. WARRANTY APPLICABLE TO PROGRAM INSURANCE COVERAGE
Premiums for this Program are the responsibility of the Metropolitan Washington Airports Authority and I agree that any and all return of premium, dividends, discounts, or other adjustments to any Program policy(ies) is assigned, transferred, and set over absolutely to the Metropolitan Washington Airports Authority. This assignment applies to the Program policy(ies) as now written or as subsequently modified, rewritten, or
replaced. Rights of Cancellation for all Program insurance policy(ies) arranged by the Metropolitan Washington Airports Authority are assigned to the Metropolitan Washington Airports Authority.
1. I will pay the cost of premium(s) for non-AVIATION OCIP Program insurance coverage, specified in the Contract Documents.
2. I authorized the release of all claim information for all insurance policies under the AVIATION OCIP.
3. It is my responsibility to notify my insurance carrier(s) that I am enrolling in the AVIATION OCIP.
4. I have omitted from my bid the insurance costs for the coverage provided by Metropolitan Washington Airports Authority.
5. The statements in this insurance application are true to the best of my knowledge.
H. Signature Block : I verify the information presented above and attachments are correct:
Print Name Date
Title Signature
Email to: Nick Morgan, Program Administrator Phone: 202-772-4244 Wells Fargo Insurance Services, Inc. Cell: 202-815-4303
1401 H Street, NW Suite 750 Fax: 877-827-0725
Washington DC 20005 Email: [email protected]
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 1GL - Enrollment Application INSTRUCTIONS
Metropolitan Washington Airports Authority
Page 3 of 3 This form must be completed and submitted by each successful Contractor and Subcontractor of any tier prior to Job Site mobilization for each contract awarded.
The Contractor and Subcontractor will submit the completed form to Wells Fargo Insurance Services (WFIS). Upon receipt of this form, WFIS will issue to the Contractor or Subcontractor a Certificate of Insurance evidencing coverage in the AVIATION OCIP. The completed Certificate of Insurance will be mailed to the Enrolled party.
A. Contractor Information
1 Enter your company’s Federal ID number. This number can be found on filings made to the federal government such as your tax return.
2 Enter your company’s business information including name, mailing address, phone/fax number, and email address for your company’s primary office location.
3 Enter the name of the person Wells Fargo should contact if questions arise. Include mailing address, phone/fax and email address, if different than A2.
4 Identify your company’s legal structure and LDBE Status by checking the boxes that apply. If the correct legal structure is not specifically listed, please check the “Other” box and specify in the space provided.
B. Contract Information
1 Enter the Contract Number or Purchase Order Number that was included in the Metropolitan Washington Airports Authority’s originating documentation.
2 Check the Job Site Location.
3 Enter the Date the Contract was awarded to your organization.
4 Provide a brief description of the work you will be performing at the project site.
5 Identify the total dollar amount of your contract.
5a Check the appropriate box that identifies if you contract directly with Metropolitan Washington Airports Authority or are a Subcontractor.
5b If you are a Subcontractor, identify the entity with who you are under contract.
6 Identify the amount of work that you anticipate will be self-performed.
7 Enter the Date you anticipate starting work and then mark whether the date provided is actual or estimated.
8 Enter the Date you anticipate completing the described work and then mark whether the date provided is actual or estimated.
C. Contacts (Requested Contact information is for specific functions. It is possible to have a single person fulfill multiple responsibilities. These individuals should be located, if at all possible, on-site.)
1 Identify your Project Manager for this Contract.
2 Identify your Safety Representative for this Contract.
3 Identify your Insurance/Risk Management Representative for this Contract.
4 Identify your Claims Representative for this Contract.
5 If applicable, identify the Metropolitan Washington Airports Authority Contracting Officer Technical Representative for your Contract.
6 If applicable, identify the Metropolitan Washington Airports Authority Contracting Officer for your Contract.
D. Current on-site and off-site Workers Compensation Information
(Information relates to your corporation’s existing coverage; identify each modification factor that applies.) 1 Enter the State that the Modification Information applies to.
2 Enter your Bureau File Number also referred to as your Risk Identification Number. This number can also be found on your Modification worksheets.
3 Enter the Bureau Rating Agency. In most states this is NCCI.
4 Provide your Company’s Anniversary Rating Date. Information can be located on your bureau’s WC Experience Modification worksheets.
5 Identify your insurance carrier for Workers Compensation coverage.
6 Provide your Workers Compensation Policy Number.
7 Provide the effective date of your Workers Compensation policy.
8 Provide the expiration date of your Workers Compensation policy.
E. Subcontractor Information
(Provide the following information for each Subcontractor that will be performing work at the project site. Use additional sheets, if necessary.) 1 Identify the name of the Subcontracting firm.
2 Provide the mailing address for the Subcontractor.
3 Provide the Trade name and NAICS for the Subcontractor.
4 Provide the estimated value of the subcontracted activity.
5 Provide a contact name, preferably the project manager, for the Subcontractor.
6 Provide the phone number, fax number, and email address for the Subcontractor.
7 Provide the date the Subcontractor is scheduled to begin work.
F. Enrollment Questions
1 Determine if you will have any locations, off-site, that will be 100% dedicated to this project. Include material/supply storage as a possible location. Mark the appropriate box (yes/no). If you answer yes – provide the address of each location you identified as 100% dedicated.
2 Mark the boxes that apply. Contemplate only work performed under this contract.
3 Mark the boxes that apply. Employee Leasing Firm are those firms that supply the labor force for your company (You direct the activities of the Leasing Company’s employees). Temporary Labor Firms supplement your labor force.
4 Enter your Virginia Contractor’s License Number.
5 Enter whether your Virginia Contractor’s License is Class A, B, or C.
G. Warranty Statements:
1-6 Read each Warranty statement thoroughly. If you have questions regarding any of these statements, contact the AVIATION OCIP Administrator identified on page 2.
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 2GL - Notice of Work Completion
Metropolitan Washington Airports Authority
Page 1 of 2
A. General Information 1. Contractor
2. Under Contract with
3. Contract #
4. Description of Work Performed
5. Date Work Completed
6. Date this Contract Completed
7. Final Contract Value $ B. Work Completion
The following Subcontractors have completed their Work at the Job Site:
(Add attachment if more space is needed)
1.
Subcontractor’s Name 2.
Contract Number
3.
Description of Work
4.
Date Completed
C. Signature Block
The undersigned acknowledges request for termination of Coverage under the AVIATION OCIP as of the date indicated above for the specified Contract. Should we return to the work Site, we will be working under our own insurance program and must provide Metropolitan Washington Airports Authority with a Certificate of Insurance showing our own Coverage as detailed in our contract.
1. Contractor’s Representative’s Signature
Print Name Date
Title Signature
2. Prime Contractor’s Representative’s Signature
Print Name Date
Title Signature
Nick Morgan, Program Administrator Phone: 202-772-4244 Email to: Wells Fargo Insurance Services, Inc. Cell: 202-815-4303 1401 H St, NW Suite 750 Fax: 877-827-0725
Washington, DC 20005 Email: [email protected]
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 2GL - Notice of Work Completion INSTRUCTIONS
Metropolitan Washington Airports Authority
Page 2 of 2 This form must be completed and returned to the AVIATION OCIP Administrator by the Contractor or Subcontractor whenever work is completed for each Contract or Subcontract.
A. General Information
1 Provide the name of the Contractor completing their work.
2 Provide the name of the Entity this Contractor has a contract with.
3 Enter the contract number for the work being completed.
4 Provide a brief description of the work being completed.
5 Provide the Date the Work was completed.
6 Provide the Date the Contract was completed, if other than the work completion date.
7 Provide the Final Contract Value.
B. Work Completion
1 Enter the name of each Subcontractor that performed work for you that has also completed their work.
2 Enter Subcontractors Contract Number.
3 Provide a brief description of their work.
4 Provide the Date they completed their work.
C. Signature Block
1 This form must be signed by a representative of your company with the Airports Authority to Verify that the information is correct.
2 Have this form approved by the Prime Contractor for the Project Site.
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 3GL - Pre-Enrollment Wells Fargo Insurance
GL OCIP Pre-Enrollment Web-Portal Form MWAA AVIATION OCIP
USER INFORMATION
Awarding (Prime) Contractor
Subcontractor Name:
Contract Number: NAICS Code
Contact person for GL OCIP Administration: Policy information, OCIP Forms, COI, etc
First Name: Last Name:
Phone Number: Email:
Physical Address
Street Address:
City: State: Zip:
Mailing Address
Same as Physical address:
Street Address:
City: State: Zip:
Wells Fargo Contact:
Nick Morgan M: 202 815 4303
A V I A T I O N O C I P F O R M S
AVIATION OCIP Form - 4GL - General Liability Loss Report
A V I A T I O N O C I P F O R M S
A V I A T I O N O C I P F O R M S
Sample Certificate to be supplied by Enrolled Contractors ONLY